The processing of medical insurance claims generated when health care providers (“providers”) perform services for patients is facilitated by computerized networks. In general, when a provider treats a patient, the provider enters certain medical insurance claim data into a computer using software programs designed for this specific use. The claim data entered into the computer is transmitted to one or more medical insurance companies. The medical insurance companies process the claims, send processed claim information back to the provider, and send financial compensation for the services rendered by the provider.
Medical insurance claim data entered into a computer by a provider generally include several types of codes, which may be, for example, numeric or alphanumeric in format. Each code represents an aspect of a provider's treatment of a patient. Types of codes include examination codes, diagnostic codes, procedure codes and supply codes. Examination codes represent the type of examination performed by a provider on a patient. Diagnostic codes represent the diagnosis(es) made by the provider concerning the patient's condition, and the procedure codes indicate what services were performed by the provider in order to treat the patient. Supply codes represent supplies used to treat the patient, such as surgical trays, medications, IV supplies, etc. A single visit by a patient to a provider may result in one or more examinations of body systems and/or body parts, one or more diagnoses, one or more procedures, and/or use of one or more supplies, each of which is represented by a code when a medical insurance claim is created and submitted to an insurance company. Moreover, for each diagnostic code, there are defined allowable procedure codes, and for each procedure code, there are defined allowable supply codes. Thus, the codes reflect that only certain procedures are appropriate in treating a given diagnosis, and that only certain supplies are appropriate for performing certain procedures.
One commonly used collection of examination, diagnostic, procedural and supply codes is published by the American Medical Association (AMA), which regularly updates and publishes its codes. The AMA also assigns point values to each examination, procedure, and supply code. These point values are used in processing medical insurance claims as described in detail below.
Before submitting claims to a medical insurance company, a provider negotiates a contract with the insurance company that dictates the terms by which the insurance company will reimburse the provider for services performed on patients insured by the insurance company. In the contract, the insurance company defines the reimbursement terms using the point values assigned to each of the AMA procedure and supply codes by assigning a conversion factor that translates the points for each procedure and supply code into a dollar value. Providers may negotiate different conversion factors with different insurance companies. The conversion factor may also vary with geographic location of the provider. In some cases, such as Medicare, the provider does not have any opportunity to negotiate the terms of reimbursement: Medicare's reimbursement terms and conversion factors are fixed.
For purposes of illustrating the existing system for processing and reimbursement of medical insurance claims, an exemplary medical insurance claim may be submitted to an insurance company as follows:
Date of Service
Patient Identification Number
Examination Code 1
Diagnostic Code 1
Procedure Code 1                Supply Code 1        
Procedure Code 2
Procedure Code 3
Diagnostic Code 2
Procedure Code 1
Procedure Code 2                Supply Code 1The date of service represents the date on which the patient was seen and treated. The patient's identification number may be the patient's Social Security Number or any other identification number, often assigned by the patient's medical insurance company. The Examination Code indicates that the provider performed a certain type of examination on the patient. The Diagnosis Codes represent the diagnoses made by the provider concerning the patient's condition, the Procedure Codes represent the procedures performed by the provider to treat the patient, and the Supply Codes indicate what supplies were used in performing the corresponding procedures.        
When a medical insurance claim is received by a medical insurance company or other medical insurance provider (“the company”), the company processes the claim either automatically or manually. Processed claim data and monetary payment are then sent to the provider, via electronic or paper means.
Processed claim data generated in response to the example claim above should be as follows:
Date of Service
Patient Identification Number
Examination 1—Amount reimbursed ($)
Diagnostic Code 1
Procedure Code 1—Amount reimbursed ($)                Supply Code 1—Amount reimbursed ($)        
Procedure Code 2—Amount reimbursed ($)
Procedure Code 3—Amount reimbursed ($)
Diagnostic Code 2
Procedure Code 1—Amount reimbursed ($)
Procedure Code 2—Amount reimbursed ($)                Supply Code 1—Amount reimbursed ($)        
In the existing system of medical insurance claim processing and reimbursement, however, mistakes are very common. It is not unusual for claims to be processed incorrectly or incompletely. For example, the conversion factor used to calculate the amount of money to be reimbursed to the provider may be incorrect, leading to incorrect payments. Also, examination and/or procedural codes may be omitted all together, such that the provider is not paid for examinations and/or procedures performed or supplies used.
These types of mistakes and omissions are difficult to track due to the shear volume of claims involved. A provider may send hundreds of claims on a weekly basis, and manually checking each one to insure proper processing and reimbursement is very burdensome. In addition, the claims must be resubmitted to the insurance company for correct processing, which adds to the burden placed on providers and insurance companies.
Consequently, there is a need for a system for health care providers to use to verify that their insurance claims are being correctly processed and paid, to assist in resubmission of incorrectly processed claims, and to assist in verifying the accuracy of claims prior to submission to the insurance company.